• Acts as an integral member of the clinical care team and educates patients about findings and recommendations
• Coaches patients about behavior changes to improve health status, reduce health risks, and improve quality of life
• Assists with the development and coordination of shared medical visits
• Assesses readiness to change and implement actions to assist patients in reaching their goals
• Empowers patients to become integral partners with their clinical care teams by teaching self-management skills and encouraging personal insight and self-activation
• Develops customized (personalized) care plans for each patient, including goals and action steps
• Provides health and wellness education utilizing a variety of strategies, including group presentations, support-group facilitation, creative use of media, newsletter contributions, etc.
• Monitors real-time participant data to view progress and/or challenges
• Prioritizes and organizes daily workflow as well as other assignments/projects to meet commitments and deadlines
• Prepares for and conducts individual or group health coaching sessions using data collected from patient InBody and/or on-site body composition analysis
• Making specific recommendations based on results as they relate to healthier lifestyles, health goals, dietary needs, etc.
• Develops individualized action plans to help patients reach their health goals and monitors progress, providing feedback, accountability, and counseling toward these goals
• Develops and implements programming for a patient population with a focus on exercise, nutrition, and overall wellness
• Partner with medical, business, and community groups to discuss outreach opportunities and promote healthy lifestyle choices in the surrounding community

Skills: Patient Education, Behavior Coaching, Care Plan Development, Readiness Assessment, Wellness Education, Progress Monitoring, Health Counseling, Community Outreach

• Target high risk via telephone, onsite, electronically, etc.
• Oversee and review reports and trends
• Review abnormal lab results with participants
• Assist all participants with goal setting to encourage healthy behaviors
• Facilitate group review of lab and biometric results
• Prepare and present quarterly coaching utilization and progress reports to Sterling client companies
• Field inbound calls regarding tthe elephonic health coaching program
• Work in collaboration with other Health Coaches to facilitate and complete physician referral calls
• Lead, assist and attend screening events
• Maintain privacy and confidentiality of health information
• Work with Sterling Wellness Program Managers to reach targeted client goals
• Motivate and inform customers through their health care choices, utilising person-centred behaviour change techniques and approved Health Coaching tools and resources
• Assist customers in developing action plans to address opportunities for health improvements that are valuable to the customer
• Achieve individual productivity measures, including recruitment volumes (by outbound calling) of new customers and call quality standards, as well as support for the attainment of team goals and business growth initiatives
• Manage an individual caseload of customers, scheduling and managing all coaching interventions in line with program guidelines

Skills: High-Risk Targeting, Report Analysis, Goal Setting, Group Facilitation, Progress Reporting, Confidentiality Maintenance, Behavior Motivation, Caseload Management

• Triage referrals from primary care clinicians to the consultative team
• Assess patients for common mental health and substance abuse conditions
• Identifies psychosocial, financial, legal, psychiatric or substance use issues that affect patient care management and collaborates with the team to support and facilitate the patient care process
• Ensure systematic screening of adults for depression, using evidence-based screening tools
• Coordinate with the behavioral health team and provide coaching support for a panel of adults with defined behavioral health needs
• Systematically review the caseload with the consulting psychiatrist and LICSW each week
• Effectively communicate treatment recommendations, assessment, and case recommendations to the referring primary care team
• Facilitate discussion of treatment plan changes when patients are not improving
• Support the primary care provider in outreach to established mental health providers for patients already engaged in treatment
• Provide brief interventions using evidence-based techniques such as Behavioral Activation, Problem-Solving Treatment, Motivational Interviewing, or other treatment appropriate for the primary care setting
• Monitor patients (in person or by phone) for changes in clinical symptoms and treatment side effects
• Support psychotropic medication management prescribed by PCPs, focusing on adherence, side effects, complications, and effectiveness
• Provide education to patients using a variety of educational materials
• Develop a maintenance plan with patients to help ensure a healthy lifestyle once in remission
• Provide or facilitate outside referrals to community-based mental health and community support services

Skills: Referral Triage, Mental Health Assessment, Patient Screening, Behavioral Health Coordination, Case Review, Treatment Communication, Brief Intervention, Patient Education

• Actively engage a panel of adult, pediatric, and/or geriatric patients
• Greet patients and families in reception, bring them back to rooms, establish an agenda, and work with the patient to ensure a pragmatic care plan is established
• Capture relevant information about the patient's health and healthcare experience, take vitals, administer point-of-care testing, and perform standard age and condition-appropriate screening assessments
• Take responsibility (in partnership with providers) for the health of a population of patients and monitor and track whether those patients are up to date on preventive measures
• Learn about the chronic health conditions that span the patient population
• Provide patient education on chronic disease management
• Provide anticipatory preventive guidance to families with children
• Establish healing relationships with members and families
• Learn to employ confidence-promoting techniques in patient communication and develop patient self-efficacy to better manage health
• Communicate with patients by phone and email and invite the physician
• Help patients understand their chronic conditions, why they matter, and how they can manage them
• Assist families and children in developing sustainable behaviors for wellness and prevention
• Coach patients using an action-planning model based on motivational interviewing techniques
• Collaborate with other team members to facilitate group events and classes for patients
• Assist with the coordination of care across the continuum, such as scheduling appointments with specialists, coordinating referrals, and sharing or transferring information with the patient's internal and external care team
• Participate broadly in the daily operations of a primary care practice, such as answering incoming phone calls, assisting with front desk inquiries, and ensuring general upkeep of the clinical space
• Learn core insurance benefits to facilitate care navigation
• Present on areas of interest/expertise in health and wellness to team members and patients
• Contribute to open team forums on problems and process improvements by listening, sharing input and ideas, and enacting decisions and plans

Skills: Patient Engagement, Care Plan Establishment, Health Screening, Chronic Disease Education, Preventive Guidance, Motivational Coaching, Care Coordination, Wellness Promotion

• Acts as the primary contact person for the patients/families with chronic disease care to ensure and promote continuity of care
• Contacts patients prior to and/or after physician visits, monitors patient compliance with the treatment plan and appointments and assists with reminder calls
• Provides ongoing communication with physicians and staff regarding patients appropriate for chronic disease care and works closely with physicians, staff and patients in coordinating chronic disease care
• Coordinates necessary patient education material
• Collaborates with physicians and staff in patient care visits using evidence-based medicine guidelines for chronic disease care
• Assists physicians utilizing Healthy Planet, running reports, and interpreting results
• Facilitates data collection and analysis of chronic disease measures and identifies opportunities for improvement
• Assists in the development of data collection tools and the collection of data related to these tools for chronic disease care
• Manages and monitors the database registries for chronic disease care and prevention, wellness
• Assists physicians and staff with clinical information regarding patients/families with chronic disease care
• Participates in the facilitation of continuous access to the medical record and plan of care
• Participates in patient safety, Joint Commission, and audits for primary care clinics
• Acts as a resource for compliance reporting and accreditation requirements according to established guidelines and within established time frames
• Maintains requirements for age-specific competencies for the position

Skills: Disease Management, Patient Communication, Care Coordination, Education Preparation, Data Collection, Registry Management, Compliance Reporting, Patient Safety

• Working experience in clinical or community health
• Working experience in motivational interviewing training
• Proficient knowledge of effective lifestyle behavior change such as tobacco cessation and weight management, and the role lifestyle plays in conditions such as diabetes and heart disease
• Demonstrated experience applying health behavior change theories and principles, such as the Transtheoretical Model and Motivational Interviewing
• Strong experience working with people to improve their health
• Demonstrates integrity, initiative, good judgment and teamwork
• Strong interpersonal relationships and communication skills, and the ability to work autonomously with a diverse patient population
• Intermediate level of experience with Microsoft Office products, with the ability to navigate a Windows environment
• Solid time management, organizational, research, analytical, and documentation skills
• Ability to work independently, efficiently, perform multi-tasking, prioritize tasks, and meet deadlines
• Proficient and confident in Windows-based computer software and able to work simultaneously and efficiently with telephone-based duties
• Strong communication skills with a demonstrated ability to educate and motivate individuals
• Professional experience in health, fitness and/or nutrition

• Experience working in a fast-paced medical office or clinical setting
• Experience navigating EMR/EHR systems and patient billing and scheduling systems
• Professional, empathetic, positive, articulate, and proactive
• Excellent verbal and written communication skills
• Flexible, team-player mentality willing to assist
• Experience working with patients with diabetes and/or cardiac-related health conditions
• Proficiency using a computer and Microsoft Office (Word, Excel, and Outlook)
• Deep knowledge of medical terminology specific to cardiac/cardiology
• Experience in facilitating patient/client positive behavioral change
• Experience in wellness-related areas such as weight management, tobacco cessation, stress management, nutrition, physical activity or health lifestyle behavior change
• Ability to work with a multidisciplinary team
• Able to articulate Iora values about service and performance

• Experience in health behavior change/health coaching/health education
• Strong knowledge of specific diseases, lifestyle-related topics, nutrition, and exercise
• Knowledge of and experience with applying the stages of change or a similar behavior change model
• Excellent interpersonal skills with the ability to foster trust and respect among customers and coworkers
• Able to work independently and remotely
• Able to work with protected health information and maintain absolute confidentiality and privacy by HIPAA regulations and AHP policies
• Excellent organizational skills with a strong attention to detail
• Proficient computer skills including Microsoft Office Excel, Word and PowerPoint
• Excellent written and verbal communication skills as well as strong telephonic relationship-building skills
• Demonstrated ability to manage multiple priorities in a dynamic environment, combined with excellent time management skills
• Experience working in a fast-paced environment in a medical or clinical office setting
• Strong critical thinking and problem-solving skills
• Flexibility in schedule, occasionally adjusting to accommodate patient and provider needs

• Must have Health Coach certification and CPR certification 
• Working experience in customer service or equivalent (e.g. hospitality, call centre, retail, etc)
• Must have medical assisting and phlebotomy certification 
• Proficient motivational interviewing skills
• Exceptional interpersonal, verbal and written communication skills
• Experience navigating EMR/EHR and scheduling/billing systems
• Ability to efficiently perform job duties in a fast-paced work environment with zero to few errors
• High level of ownership, accountability and initiative
• Flexible with a team-player mentality
• Ability to work collaboratively and efficiently in an intimate clinical setting
• Must be proficient with Motivational Interviewing, Cognitive Therapy, and DBT
• Extensive knowledge of Microsoft Word, Excel, and PowerPoint
• Working experience in Health Coaching 
• Excellent command of spoken and written English and excellent IT skills

• Must have Certification from an accredited professional health coach training program
• Critical thinking skills, decisive judgment and the ability to work with minimal supervision
• Must be able to work in a fast-paced environment and take appropriate action
• Expertise in helping patients prevent and/or improve management of lifestyle-related chronic conditions using strategies such as smoking cessation, weight management, dietary interventions, stress reduction, and exercise
• Must have CAADC certification through MCBAP 
• Must be Bilingual in English and Spanish 
• Previous mental health and/or substance abuse assessment and treatment experience
• Ability to work well independently and as part of a team
• Comfortable working through ambivalence and resistance with customers
• Strong communication skills - writing, typing and phone
• Must be open to feedback and have a desire to continuously learn and grow
• Clinical experience such as EMT, MA, CNA, or Phlebotomy certification
• Working experience in health and wellness 
• Previous experience with Motivational Interviewing skills